Provider Demographics
NPI:1982727111
Name:PLACE, JENNIFER LEIGH (OD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:PLACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:PRYBYLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2550 S TELEGRAPH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0950
Mailing Address - Country:US
Mailing Address - Phone:248-258-9000
Mailing Address - Fax:248-499-6372
Practice Address - Street 1:2550 S TELEGRAPH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0950
Practice Address - Country:US
Practice Address - Phone:248-258-9000
Practice Address - Fax:248-499-6372
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5330000086152W00000X
MI4901004123152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E04240OtherBLUE CROSS
MIJP004123OtherBLUE CROSS BLUE SHIELD
MI1GV09539OtherCIGAN HEALTHCARE
MI1GV09539OtherCIGAN HEALTHCARE
MIJP004123OtherBLUE CROSS BLUE SHIELD